Provider Demographics
NPI:1225604093
Name:SISSON, KELLY (AGACNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SISSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 PROFESSIONAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3335
Mailing Address - Country:US
Mailing Address - Phone:404-962-6000
Mailing Address - Fax:404-962-6001
Practice Address - Street 1:575 PROFESSIONAL DR STE 400
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3335
Practice Address - Country:US
Practice Address - Phone:404-962-6000
Practice Address - Fax:404-962-6001
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191117363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care